ObjectiveTo determine if topical administration of local anesthesia, applied to fresh skin-harvest sites, reduces pain and analgesic requirements after surgery. Summary Background DataNonopioid treatments for pain after therapeutic procedures on patients with burns have become popular because of the side effects associated with narcotics. The topical administration of local anesthesia originally offered little advantage because of poor epidermal penetration. MethodsThis study compares 2% lidocaine with 0.5% bupivacaine or saline, topically applied after skin harvest, to determine what effect this may have on pain and narcotic use. Sixty patients with partial-or full-thickness burns to approximately 10% to 15% of their body were randomly divided into three groups: group 1 received normal saline, group 2 had 0.5% bupivacaine, and group 3 had 2% lidocaine sprayed onto areas immediately after skin harvest. Blood samples were subsequently obtained to measure concentrations of the local anesthetic. Hemodynamic variables after surgery, wake-up times, emetic symptoms, pain, and narcotic use were compared. ResultsHigher heart rates were noted in the placebo group than in those receiving lidocaine or bupivacaine. No differences were noted in recovery from anesthesia or emetic symptoms. Pain scores were lower and 24-hour narcotic use was less in patients who received lidocaine. Plasma lidocaine levels were greater than bupivacaine at all time points measured. ConclusionsTopical lidocaine applied to skin-harvest sites produced an analgesic effect that reduced narcotic requirements compared with patients who received bupivacaine or placebo. Local anesthetic solutions aerosolized onto skin-harvest sites did not affect healing or produce toxic blood concentrations.One of the major problems faced by patients during recovery from burn injury is the pain of repeated therapeutic procedures.1 Pain from skin debridement and grafting procedures may be an important factor in the development of psychiatric disorders and depression, especially if control of pain is inadequate. The perception of pain from a given stimulus is influenced by numerous factors, including patient variability, ethnic background, socioeconomic class, previous life experiences, and support systems.2 About 52% of patients report pain during burn wound debridements, whereas 84% describe extreme pain after therapeutic procedures.2 The size and depth of the burn injury may also influence the amount of perceived pain.Opioid administration is the dominant form of analgesic therapy in this patient population.2 The pharmacokinetics of opioids are altered in patients with burn injury, both immediately after the event and for weeks to come because of changes in the volume of distribution, unbound drug fraction, clearance half-life, and sensitivity. In addition, opioid requirements may increase over time, may reach a ceiling effect, and may not be able to provide complete analgesia in 115Address reprint requests to W.

Aggressive control of pain during the immediate postoperative period after cardiac surgery with early tracheal extubation may decrease morbidity and mortality. This prospective, randomized, double-blinded, placebo-controlled clinical study examined the use of intrathecal morphine in patients undergoing cardiac surgery and its influence on early tracheal extubation and postoperative analgesic requirements. Patients were randomized to receive either 10 micrograms/kg of intrathecal morphine (n = 19) or intrathecal placebo (n = 21). Perioperative anesthetic management was standardized (intravenous (IV) fentanyl, 20 micrograms/kg, and IV midazolam, 10 mg) and included postoperative patient-controlled morphine analgesia. Of the patients who were tracheally extubated during the immediate postoperative period, the mean time from intensive care unit arrival to extubation was significantly prolonged in patients who received intrathecal morphine (10.9 h) when compared to patients who received intrathecal placebo (7.6 h). Three patients who received intrathecal morphine had extubation substantially delayed because of prolonged ventilatory depression. Although mean postoperative IV morphine use for 48 h was less in patients who received intrathecal morphine (42.8 mg) when compared to patients who received intrathecal placebo (55.0 mg), the difference between groups was not statistically significant. In conclusion, intrathecal morphine offers promise as a useful adjunct in controlling postoperative pain in patients after cardiac surgery. However, the optimal dose of intrathecal morphine in this setting, along with the optimal intraoperative baseline anesthetic that will provide significant analgesia, yet not delay extubation in the immediate postoperative period, remains to be elucidated.

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